TMJ examination & History

Cranial nerve examination:

Eye examination (diplopia & blurriness)

Ear examination (hearing, press on tragus to identify otitis externa) and otoscopy

Cervical examination: neck movements right and left (45 degrees) Up (60 degrees) down (45 degrees)
rotation (70 degrees)

Muscle examination with middle 3 fingers with 1-2 second thrusts

- Temporalis

Anterior region above the arch and anterior to TMJ

Middle region on top of TMJ and above the arch

Posterior region above & behind the arch

Tendon region coronoid process intraorally

- Masseter

Superiorly just below arch

Inferiorly inferior border of ramus

Sternocleidomastoid: whole length of muscle

Posterior cervical muscles

Trapezius, splenis capitis, longismus, levator scapulae.

All these muscles are difficult to identify individually TMD

Trigger point injection: differentiates between arthrogenic &myogenic pain

Mahan Sign: loading of tongue spatulas on affected side in canine relieves pain and if loaded on contra-
lateral side pain is increased. Positive in Wilkes stage III, IV, V and sometimes in II.

Functional manipulation of muscles not amenable to palpation

- Lateral Pterygoid protrusion against resistance, clenching teeth (stretching)

- Medical Pterygoid clenching of teeth (contraction), opening of mouth (stretching)

Maximum interincisal distance: Any distance <40mm

End feel: gentle steady pressure on lower incisors causes increase in mouth opening (muscle disorder)

Lateral movement < 8mm is restricted

Protrusive movement < 8 mm is restricted

Path of opening: deviation:

- Returns to normal (disc displacement)

- Does not return to middle (restricted movement in one joint)

Extracapsular restriction

If restricting muscle is lateral to joint deflection is ipsilateral

If restricting muscle is medial to joint deflection is contralateral

Lateral movements are not effected

Intra capsular restriction: limitation in opening or rotation of joint, further opening is restricted due to
structured interference not pain.

Medial pterygoid: bimanual palpation, angle of mandible and lingual vestibule in retromolar region

Lateral pterygoid: posterior to maxillary tuberosity

Palpation of joint

Lateral aspect with mouth closed

Lateral aspect with mouth open

Posterior aspect with mouth open

Joint sounds

Palpation

Auscultation

Click (disc displacement), pop, crepitation (degenerative conditions)

Dental examination

Tooth mobility (clinical examination, radiographic examination)

Pulpitis, tooth fracture

Dental trigger points

Temporalis: maxillary teeth

Masseter : mandibular and maxillary posterior teeth

Anterior belly of digastric: Mandibular anteiror teeth only

Tooth wear: parafunctional habits

Abfractions: parafunctional habits

Occlusal examination

Centric relation: musculoskeletal stable position where 20mm of pure rotation movement can take
place. Note occlusion here. Best done by patient lying down and looking upwards.

Pain in establishing this relation suggests intra capsular disorders

Maximum intercuspation

If force applied to teeth during CR results in no shift then CR & MI are coincident. Normal division 1-
2mm

Arch integrity:

Missing teeth

Carious teeth

Drifting

Tipping

Supra-eruption

Systemic examination

Bouchard nodes: PIP (proximal interphalangeal) joint growth osteoarthritis

Hands for heberdens nodes osteoarthritis (abnormal bony growth of DIP)

Ulnar drift of rheumatoid arthritis

Palpation of superior temporal artery for nodularity and tenderness (temporal arteritis)

Auriculotemporal nerve block. https://www.youtube.com/watch?v=ZKhuzn9jy9k

Open & close the mouth of patient

Open the moth wide

Paplate neck of condyle (1-1.5cm below tragus )

Insure needle posterior to mandible to a depth of 13mm